ELIGIBLE STATUS

1. Subscribers. To be eligible under this plan, you must be an eligible employee as determined by the group's rules and regulations. 2. Family Members. Under this plan, you may select one of the

following eligibility options for your family members, either Standard Family Member Coverage or Union Negotiated Family Member Coverage:

A. Standard Family Coverage

The following persons are eligible for the subscriber to enroll as family members: (a) The subscriber’s spouse or domestic partner; and (b) an eligible unmarried child.

Definition of Family Member

1. Spouse is the subscriber’s spouse as recognized under state or federal law. This includes same sex spouses when legally married in a state that recognizes same-sex marriages. Spouse does not include any person who is covered as a subscriber or domestic partner.

2. Domestic partner is the subscriber's domestic partner under a legally registered and valid domestic partnership. Domestic partner does not include any person who is covered as a subscriber.

3. Child is the subscriber’s, spouse’s or domestic partner’s natural child, stepchild, legally adopted child, or a child for whom the subscriber, spouse, or domestic partner has been appointed legal guardian by a court of law, subject to the following:

a. The child is under 26 years of age.

b. The unmarried child is 26 years of age or older and: (i) was covered under the prior plan, was covered as a family member of the subscriber under another plan or health insurer, or has six or more months of other

creditable coverage, (ii) is chiefly dependent on the subscriber, spouse or domestic partner for support and maintenance, and (iii) is incapable of self-sustaining employment due to a physical or mental condition. A physician must certify in writing that the child is incapable of self-sustaining employment due to a physical or mental condition. We must receive the certification, at no expense to us, within 60-days of the date the subscriber receives our request. We may request proof of continuing dependency and that a physical or mental condition still exists, but not more often than once each year after the initial certification. This exception will last until the child is no longer chiefly dependent on the subscriber, spouse or domestic partner for support and maintenance due to a continuing physical or mental condition. A child is considered chiefly dependent for support and maintenance if he or she qualifies as a dependent for federal income tax purposes.

c. A child who is in the process of being adopted is considered a legally adopted child if we receive legal evidence of both: (i) the intent to adopt; and (ii) that the subscriber, spouse or domestic partner have either: (a) the right to control the health care of the child; or (b) assumed a legal obligation for full or partial financial responsibility for the child in anticipation of the child’s adoption.

Legal evidence to control the health care of the child means a written document, including, but not limited to, a health facility minor release report, a medical authorization form, or relinquishment form, signed by the child’s birth parent, or other appropriate authority, or in the absence of a written document, other evidence of the subscriber’s, the spouse’s or domestic partner’s right to control the health care of the child.

d. A child for whom the subscriber, spouse or domestic partner is a legal guardian is considered eligible on the date of the court decree (the “eligibility date”). We must receive legal evidence of the decree.

B. Union Negotiated Family Coverage

The following persons are eligible for the subscriber to enroll as

family members: (a) The subscriber’s spouse or domestic

partner; and (b) an eligible unmarried child of the subscriber or spouse.

Definition of Family Member

1. Spouse is the subscriber’s spouse as recognized under state or federal law. This includes same sex spouses when legally married in a state that recognizes same-sex marriages. Spouse does not include any person who is covered as a subscriber or domestic partner.

2. Family Members. The following are eligible for the subscriber to enroll as family members: (a) The subscriber’s spouse or domestic partner; and (b) an unmarried child of the subscriber or spouse.

Definition of Family Member

1. Spouse is the subscriber’s spouse under a legally valid marriage between persons of the opposite sex. Spouse does not include any person who is covered as a subscriber or domestic partner.

2. Domestic partner is:

a. The subscriber's domestic partner under a legally registered and valid domestic partnership. Domestic partner does not include any person who is covered as a subscriber; or

b. For a domestic partnership, other than one that is legally registered and valid, in order for the subscriber to include their domestic partner as a family member, the subscriber and domestic partner must meet the following requirements:

i. Both persons have a common residence.

ii. Neither person is married to someone else nor a member of another domestic partnership with someone else that has not been terminated, dissolved, or adjudged a nullity.

iii. The two persons are not related by blood in a way that would prevent them from being married to each other in California, or if they reside in another state or commonwealth, that state or commonwealth;

iv. Both persons are at least 18 years of age. v. Both persons are capable of consenting to the

domestic partnership.

vi. Both partners must provide the group with a signed, notarized, affidavit certifying they meet all of the requirements set forth in 2.a through 2.e above, inclusive.

As used above, "have a common residence" means that both domestic partners share the same residence. It is not necessary that the legal right to possess the common residence be in both of their names. Two people have a common residence even if one or both have additional residences. Domestic partners do not cease to have a common residence if one leaves the common residence but intends to return.

Domestic partner does not include any person who is covered as a subscriber.

3. Child is the subscriber’s or spouse’s natural child, stepchild, legally adopted child, or a child for whom the subscriber or spouse has been appointed legal guardian by a court of law, subject to the following:

a. The child is under 26 years of age.

b. The unmarried child is 26 years of age or older and: (i) was covered under the prior plan, was covered as a family member of the subscriber under another plan or health insurer, or has six or more months of other creditable coverage, (ii) is chiefly dependent on the subscriber or spouse for support and maintenance, and (iii) is incapable of self-sustaining employment due to a physical or mental condition. A physician must certify in writing that the child is incapable of self-sustaining employment due to a physical or mental condition. We must receive the

certification, at no expense to us, within 60-days of the date the subscriber receives our request. We may request proof of continuing dependency and that a physical or mental condition still exists, but not more often than once each year after the initial certification. This exception will last until the child is no longer chiefly dependent on the subscriber or spouse for support and maintenance due to a continuing physical or mental condition. A child is considered chiefly dependent for support and maintenance if he or she qualifies as a dependent for federal income tax purposes.

c. A child who is in the process of being adopted is considered a legally adopted child if we receive legal evidence of both: (i) the intent to adopt; and (ii) that the subscriber or spouse have either: (a) the right to control the health care of the child; or (b) assumed a legal obligation for full or partial financial responsibility for the child in anticipation of the child’s adoption.

Legal evidence to control the health care of the child means a written document, including, but not limited to, a health facility minor release report, a medical authorization form, or relinquishment form, signed by the child’s birth parent, or other appropriate authority, or in the absence of a written document, other evidence of the subscriber’s or the spouse’s right to control the health care of the child.

d. A child for whom the subscriber or spouse is a legal guardian is considered eligible on the date of the court decree (the “eligibility date”). We must receive legal evidence of the decree.